I agree with all that Hatch presented especially the headline quote. It is all about collaboration. Her primary premiss is that we are putting patients into categories by conditions (i.e. diabetes, heart disease, etc.) when patients with the same conditions are different. She gives the example of depression and notes that for her depression is a billing condition and not relevant to treatment planning for a vast array of patients, those in mourning, postpartum moms, isolated geriatric patient, etc. Hatch further addressed how population health is failing in the physicians office.

“When the population health need gets attention, is it at the expense of the individual’s need? Care plans driven by population health diagnostic categories are more formulaic, symptom-focused and may ignore root causes. As such, they are less likely to be successful. Then, when patients fail in flawed care plans, we indulge in blaming and name-calling: “non-compliant” or “non-adherent.”

Hatch continues her logic with the thought that non-adherence is resistance by the patient to different forces such as cost, the patient sense the drug or therapy is not working, and other factors. Her solution and rightly so is to help patients ‘choose their own adventure’ to identify their pathways to health and success.

“…when people self-identify needs and self-refer to services, their participation rate increases up to 20x. People own their choices because their choices are personally driven for their own benefit. It’s not only better for workflow, it’s better for outcomes.”

In my opinion Hatch argues clearly and is spot on when it comes to motivating patients. It is all about self-identified goals and management from the bottom up (patient) not the top down (HCP). But I would add to this the work of Malcolm Knowles who studied how adults learn. If we understand and use adult learning we can improve patient motivation.

Knowles characterized adult learning as follows:

Self-concept: As a person matures his self concept moves from one of being a dependent personality toward one of being a self-directed human being

Experience: As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning.

Readiness to learn. As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles.

Orientation to learning. As a person matures his time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centredness.

Motivation to learn: As a person matures the motivation to learn is internal

This can be summed up in the simple idea, adults will only learn when they are seeking solutions to problems they have. I posted this a couple of years ago on Knowles.

What Hatch is addressing can be seen as HCP and the healthcare system not helping patients identify the problems they are having and demonstrating solutions to those problems. The idea is to aid patients in becoming motivated through learning and self-identifying problems they may not realize they or others with similar conditions are having. As much as HCP want to be educators (Hatch’s top down idea) HCP must focus on learning what the needs/problems patients are having specific to their conditions. Personalized healthcare focused on the problems/needs/motivations of a patient is as important as matching a patient genetics to treatment, it needs to become personalized learning for the patient. You know the whole give him a fish teach her to fish thing.

I saw John Wick Chapter 2. Fast, fabulous, frenetic, feast of furious fun. And it was good, though that body count was similar to watching Miguel or Ben my Destiny pals on a strike. High triple digits. A couple of points to make

The fight scenes both hand to hand and gun battles were masterpieces that reminded me of Balanchine, Nureyev, Fonteyn, Graham, or Baryshnikov. Though I there were some scenes that felt Rodgers and Astaire. Sheer magic.

Their moves as magical as John WickPure art and balance like John Wick

A glitch of sorts in the film that was a bit jarring. Of course John Wick 2 took place in NYC. Of course there MUST be a NYC Subway chase and fight. So they (Wick & Bad Hombre) start fighting and shooting I think 42nd street. Suddenly they are at the Oculus WTC downtown in the PATH station, without taking a train. Next they they fight their way onto a PATH train and the announcer is saying ‘next stop for the A Train is Canal Street’. That is uptown. The PATH does not go to Canal Street. Then it is announced Rector Street next stop, which is downtown…wtf. The guys next to me in the theater are cracking up. Okay suspend reality for a good film.

There was a scene where Wick is selecting weapons similar to Bond with Q. This guy is called the Sommelier and is located in a wine cellar. Well done. And the sections of weapons are matched to meal courses, of course. I was all Jelly. I want that for me when selecting weapons in Destiny for PvP or PvE. I know I can watch videos read Wiki’s but, I want to be hand served.

I was looking at my archives and found Notes & Links: October 21, 2013. I posted a piece that Dan Munro a healthcare contributor at Fobes had on Obamacare Numbers Success or Failure? Munro noted that there were 476,000 health insurance application were filled through ACA Federal and State exchanges. Since then we can say a few more Americans have applied with over 20 million people have health insurance either through public o private options. As of December 24, 2016 there were 11.5 million people who used the federal marketplace to buy health insurance. 8.9 million renewed their coverage or bought new plans to replace existing plans. 2.6 million new people enrolled. It was so cute that Munro ends that piece from 2013 noting that the ACA is the single biggest target on Obama’s back. You think.

Fast forward to Munro article in Forbes Trump Acknowledges That The ‘Replacement’ Of Obamacare Will Span Years. This was pulled from President Trumps interview with Bill O’Reilly. Besides the fact Trump is seeing that the ACA can’t be just turned off without doing great harm to millions of Americans. Ultimately in rich and ironic way the GOP is being forced think about outcomes that are not tied to punishing former President Obama. GOP oh my. Which brings me to my final thought here.

As the ACA is repealed, replaced, or repaired there will be reams of pages written about the harm these actions will have on the sick, the old, and the young. There will be competing projections of what these changes will produce. For now the little we know about what will be done or considered is not enough to get our outcomes arms around.

I would like to imagine that someone, some academic institution, some group of thinkers will set up a site to track key healthcare outcomes retrospectively from the beginning of the ACA to its ‘repair’ and then going forward. Surely there will be measures of those who have and don’t have health insurance and measures of cost of health insurance and more. I am hoping we can get into the granular data that may takes years to revel a trend.

Just to throw out some ideas: Measure standards of care treatments and their outcomes for specific conditions. Compare Repaired ACA to Pre-Repaired to Non-ACA health insurance. Will we see worse outcomes in one group vs. the other group?. Are treatments offered as first line differ between measured segments? Is the life expectancy for similar diseases and patients shorter or longer between segments?

I am not a statistician nor an epidemiologist (obviously). So I’m not sure any of this can be done. Should it be done? Yes, because this is the type of evidence (not alternative facts) that the fix and repair GOP made into law. We need to know if it’s keeping Americans alive and healthy. This GOP driven destruction of Americas health is similar to the Death Panels feared in 2012 by the GOP. Now they get to enact their dream, thinning the herd of poor, sick, and non-GOP voters.

“Now would be a good time to have end-of-life discussions with Donna,” the Hospice Rabbi said. “What does she want for her funeral? What are her regrets? Did she find joy in her life?”

Joy? I failed her. All I could do was think of that.

I hesitated for a day. Then next afternoon, alone in the room with Donna, I looked at her in the bed and said, “Donna, perhaps you want to talk about your funeral.”

She looked over at me and said, “Don’t be a maudlin pussy.” Then she rolled onto her side and fell asleep.

I smiled. That was the woman I married 28 years ago, life and death on her terms, her way, take no prisoners, with no doubt about what was needed. She was not dead yet.

This occurred about a week to ten days prior to Donna’s death. Yet my grief was an orchard in full bloom and thriving finding nourishment from the memories of our life together. It took seed when she was diagnosed with Stage IV cancer two plus years earlier. After she died it sunk it roots deep and remains part of me. Many may see my grief as a failure to launch away from the pain. You know that entire finding closure meme which is denial said pretty. I will not deny my grief nor Donna.

There is more to grief. Let me defend grief, specifically defend my grief and hopefully your grief. Grief is life’s artesian aquifer. It flows from within, bored out of the loss of a loved one.It is part love and light. It holds promise to satisfyingly quench our loss. To sustain us.

Grief should not be seen as a proper place or an improper place. It is the space between memories of the past and hope for the future. Those are distant points on a compass that intersects within us. At times where it overlaps may be a soft and subtle or hard and painful. No matter it creates a newness within us offering a fresh look that what was, what is, and what may be. If choose not shy from it or ignore it can open up new memories and new understanding.

I have written about grief and will continue to. Grief has its own narrative arc and begins as thumping numbing recognizing that what once is is now was. It moves with us and becomes dullness. We need to take grief and partner with it, in a sense embrace its strength and aching to create new.

She relates the story of Floyd Hastings and the death of his wife. How Hastings like many of us who face the loss of a loved one sought to give back to those who helped us care for our loved one. I remembered the chemo lab nurses and hospice staff for years following Donna’s death. I have posted about Donna and podcast on grief and how I’ve managed it well and not so well. I am volunteering. All of this as a way to pay forward what I’ve learned.

That is what we do but more to my premiss, our grief is a light within us to guide us to a better understanding of what was, is, and will be. Below are some links to my podcasts on the topic and posts. But stay tuned more to come.

Time moves forward and we as humans move with time. Time and our lives get twisted as we move though life. Whether it’s paddling forward with the current to find a shoreline where we stop to explore. Or being carried downstream passing the point where familiar become unfamiliar. That is the polynomial equation of life: time, age, and reflection.

These past few years being carried by events surrounding me. Not powerless to changes as much as listless and supine. Donna became ill, passed away, my business and work became nonexistent. Meaning and purpose that were once part of life became abstract thoughts and longings for a time that was. This is aging. Many have written about aging especially the site Time Goes By. His thoughts and reflections on this and other aging topics are well considered and highly reflective. Yet there are moments or small events that buoy one to feel, all is not lost as we approach out expiration date.

Bronx Baking Company is one of these moments for me. I want to 1. Reflect on this company and its owner who I personally know and relate it to me then and now. 2. Give a shoutout to a fabulous company and product.

Alexis is the founder and owner of Bronx Baking. I met her through the space I was renting a desk at during Donna’s illness and death. When we first met she was mulling over the idea of a Bakery. I was struck by her drive and brains. And her Bronx attitude. She takes no shit. Kind of fits into my reference point for women.

Alexis was born and raised in the Bronx on Arthur Ave. She has an enthusiasm verging on aggressive for the Bronx. So the location was set for her. Next came the product, real German style pretzels. Alexis set out to find recipes, talk to German Bakers, test, sample, and do it all over until they were perfect. And then she started baking. At first small. Then in a shared space. And now her own space. When she opened her own space she bought equipment, cleaned the space, set it up, and tested production. To her getting here feels like forever and feels like failure delayed. For me watching it is so fast and just another step to proving your meaning and purpose. All the while she was selling product to new customers. Improving the recipe. Solving delivery problems. Snaking a grease trap. Managing account receivable. Tweeting, Instagraming, Facebooking, and more. Metaphorically those pretzels are made with sweat and tears. Metaphorically, ok. A delicious pretzel.

I could go on. There is really nothing unique here for anyone that started and ran a small business. Big deal. Or not. Consider the fact that in the US about 3% to 4% of Americans start a business. Failure is part and parcel of owning a small business as is working your ass off, having debt, and loosing sleep every night. As I said, an average day nothing special for a business owner.

I watched Alexis. I helped her with some marketing. I tried to be a cheerleader. All the while in my mind I kept thinking I was there once. My friends were there once. This is so inspiring to see and know that what we did in old timey days still feels the same. The damn the torpedo and full fucking steam ahead let’s do this lives in the Bronx, in her pretzels, and in Alexis. It lives in those that create an app or drive for Lyft. It lives in those who want to find a way to thrive and not submit. And there my friends is the importance of this. My life’s meaning and purpose may be on the wane either from external issues or from my own being stuck in this emotional amber of life. Watching Alexis and Bronx Baking and in a small way being part of it and it is thrilling. I relieve what once was. I get motivated to do this and that. I am learning new things. Being in the presence of my past is keeping me centered on the present. Helping Alexis and Bronx Baking helps me. And she gives me a pretzel once in a while.

Why Bronx Baking?

Bronx Baking sells some serious real German style pretzels and pretzel bread. They are sold locally in NYC at bars and restaurants. Where great beer is made. Alexis offers them retail (here). Do yourself a favor, you like beer? A pretzel is a must have side dish. Get some for yourself and see. You can thank me later.